Does the use of high PEEP levels prevent ventilator-induced lung injury?

Guillermo Bugedo, Jaime Retamal, Alejandro Bruhn, Guillermo Bugedo, Jaime Retamal, Alejandro Bruhn

Abstract

Overdistention and intratidal alveolar recruitment have been advocated as the main physical mechanisms responsible for ventilator-induced lung injury. Limiting tidal volume has a demonstrated survival benefit in patients with acute respiratory distress syndrome and is recognized as the cornerstone of protective ventilation. In contrast, the use of high positive end-expiratory pressure levels in clinical trials has yielded conflicting results and remains controversial. In the present review, we will discuss the benefits and limitations of the open lung approach and will discuss some recent experimental and clinical trials on the use of high versus low/moderate positive end-expiratory pressure levels. We will also distinguish dynamic (tidal volume) from static strain (positive end-expiratory pressure and mean airway pressure) and will discuss their roles in inducing ventilator-induced lung injury. High positive end-expiratory pressure strategies clearly decrease refractory hypoxemia in patients with acute respiratory distress syndrome, but they also increase static strain, which in turn may harm patients, especially those with lower levels of lung recruitability. In patients with severe respiratory failure, titrating positive end-expiratory pressure against the severity of hypoxemia, or providing it in a decremental fashion after a recruitment maneuver, is recommended. If high plateau, driving or mean airway pressures are observed, prone positioning or ultraprotective ventilation may be indicated to improve oxygenation without additional stress and strain in the lung.

Conflict of interest statement

Conflicts of interest: None.

Figures

Figure 1
Figure 1
Mean airway pressures in Oscillate (squares) and Oscar (circles) studies. Data are from tables 3S and 4S (Oscillate) and from table 2 (Oscar). In the Oscar trial, mean airway pressures in the control arm were not given and were calculated as Pmean=PEEP + 1/3(Δ Pplateau-PEEP), considering an inspiratory time from 1:2. HFOV - high-frequency oscillatory ventilation.
Figure 2
Figure 2
Effect of increasing levels of positive end-expiratory pressure on alveolar recruitment, tidal recruitment and derecruitment and static strain. From zero end-expiratory pressure to a positive end-expiratory pressure of 5cmH2O, there was marked recruitment and a decrease in recruitment and derecruitment, which provided a protective effect. Positive end-expiratory pressure levels above 15cmH2O should be carefully titrated, as the impact on recruitment is less evident and strain may increase.
Figure 3
Figure 3
Effect of different tidal volumes on tidal recruitment and derecruitment, partial pressure of carbon dioxide levels and transpulmonary pressure. A decrease in tidal volume will always induce a decrease in transpulmonary pressure, but a very low tidal volume may increase partial pressure of carbon dioxide and decrease pH. Vt - tidal volume; R/D - tidal recruitment and derecruitment; PaCO2 - partial pressure of carbon dioxide; PL - transpulmonary pressure.

References

    1. Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013;369(22):2126–2136. Erratum in N Engl J Med. 2014;370(17):1668-9.
    1. Acute Respiratory Distress Syndrome Network. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–1308.
    1. Bein T, Grasso S, Moerer O, Quintel M, Guerin C, Deja M. The standard of care of patients with ARDS ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med. 2016;42(5):699–711.
    1. Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347–354.
    1. Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome a randomized controlled trial. JAMA. 1999;282(1):54–61.
    1. Gattinoni L, Pesenti A. The concept of "baby lung". Intensive Care Med. 2005;31(6):776–784.
    1. Brochard L, Roudot-Thoraval F, Roupie E, Delclaux C, Chastre J, Fernandez-Mondejar E. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome The Multicenter Trail Group on Tidal Volume reduction in ARDS. Am J Respir Crit Care Med. 1998;158(6):1831–1838.
    1. Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome Pressure- and Volume-Limited Ventilation Strategy Group. N Engl J Med. 1998;338(6):355–361.
    1. Brower RG, Shanholtz CB, Fessler HE, Shade DM, White P Jr, Wiener CM. Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome patients. Crit Care Med. 1999;27(8):1492–1498.
    1. Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT, National Heart, Lung, and Blood Institute ARDS Clinical Trials Network Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327–336.
    1. Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, Davies AR, Hand LE, Zhou Q, Thabane L, Austin P, Lapinsky S, Baxter A, Russell J, Skrobik Y, Ronco JJ, Stewart TE, Lung Open Ventilation Study Investigators Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome a randomized controlled trial. JAMA. 2008;299(6):637–645.
    1. Mercat A, Richard JC, Vielle B, Jaber S, Osman D, Diehl JL, Lefrant JY, Prat G, Richecoeur J, Nieszkowska A, Gervais C, Baudot J, Bouadma L, Brochard L. Expiratory Pressure Study Group Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome a randomized controlled trial. JAMA. 2008;299(6):646–655.
    1. Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome systematic review and meta-analysis. JAMA. 2010;303(9):865–873.
    1. Gattinoni L, Caironi P. Refining ventilatory treatment for acute lung injury and acute respiratory distress syndrome. JAMA. 2008;299(6):691–693.
    1. Kacmarek RM, Villar J, Sulemanji D, Montiel R, Ferrando C, Blanco J, Koh Y, Soler JA, Martinez D, Hernández M, Tucci M, Borges JB, Lubillo S, Santos A, Araujo JB, Amato MB, Suárez-Sipmann F, Open Lung Approach Network Open Lung Approach for the Acute Respiratory Distress Syndrome A Pilot, Randomized Controlled Trial. Crit Care Med. 2016;44(1):32–42.
    1. Protti A, Andreis DT, Monti M, Santini A, Sparacino CC, Langer T. Lung stress and strain during mechanical ventilation any difference between statics and dynamics? Crit Care Med. 2013;41(4):1046–1055.
    1. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–755.
    1. ART Investigators Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART) study protocol for a randomized controlled trial. Trials. 2012;13:153–153.
    1. Marini JJ. Should We Embrace the "Open Lung" Approach? Crit Care Med. 2016;44(1):237–238.
    1. Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006;354(17):1775–1786.
    1. Cressoni M, Cadringher P, Chiurazzi C, Amini M, Gallazzi E, Marino A. Lung inhomogeneity in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2014;189(2):149–158.
    1. Dreyfuss D, Ricard JD, Gaudry S. Did studies on HFOV fail to improve ARDS survival because they did not decrease VILI? On the potential validity of a physiological concept enounced several decades ago. Intensive Care Med. 2015;41(12):2076–2086.
    1. Severgnini P, Selmo G, Lanza C, Chiesa A, Frigerio A, Bacuzzi A. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013;118(6):1307–1321.
    1. PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiolog. Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial) a multicentre randomised controlled trial. Lancet. 2014;384(9942):495–503.
    1. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, Marret E, Beaussier M, Gutton C, Lefrant JY, Allaouchiche B, Verzilli D, Leone M, De Jong A, Bazin JE, Pereira B, Jaber S, IMPROVE Study Group A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428–437.
    1. Protti A, Cressoni M, Santini A, Langer T, Mietto C, Febres D. Lung stress and strain during mechanical ventilation any safe threshold? Am J Respir Crit Care Med. 2011;183(10):1354–1362.
    1. Marini JJ, Ravenscraft SA. Mean airway pressure: physiologic determinants and clinical importance--Part 2: Clinical implications. Crit Care Med. 1992;20(11):1604–1616.
    1. Caironi P, Cressoni M, Chiumello D, Ranieri M, Quintel M, Russo SG. Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2010;181(6):578–586.
    1. Bugedo G, Bruhn A, Regueira T, Romero C, Retamal J, Hernández G. Positive end-expiratory pressure increases strain in patients with ALI/ARDS. Rev Bras Ter Intensiva. 2012;24(1):43–51.
    1. Retamal J, Bugedo G, Larsson A, Bruhn A. High PEEP levels are associated with overdistension and tidal recruitment/derecruitment in ARDS patients. Acta Anaesthesiol Scand. 2015;59(9):1161–1169.
    1. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, Rowan K, Cuthbertson BH. OSCAR Study Group High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med. 2013;368(9):806–813.
    1. Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P, Zhou Q, Matte A, Walter SD, Lamontagne F, Granton JT, Arabi YM, Arroliga AC, Stewart TE, Slutsky AS, Meade MO. OSCILLATE Trial InvestigatorsCanadian Critical Care Trials Group High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med. 2013;368(9):795–805.
    1. Determann RM, Royakkers A, Wolthuis EK, Vlaar AP, Choi G, Paulus F. Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury a preventive randomized controlled trial. Crit Care. 2010;14(1):R1–R1.
    1. Retamal J, Bergamini BC, Carvalho AR, Bozza FA, Borzone G, Borges JB, L. Non-lobar atelectasis generates inflammation and structural alveolar injury in the surrounding healthy tissue during mechanical ventilation. Crit Care. 2014;18(5):505–505.
    1. Cressoni M, Chiurazzi C, Gotti M, Amini M, Brioni M, Algieri I. Lung inhomogeneities and time course of ventilator-induced mechanical injuries. Anesthesiology. 2015;123(3):618–627.
    1. Bruhn A, Bugedo D, Riquelme F, Varas J, Retamal J, Besa C. Tidal volume is a major determinant of cyclic recruitment-derecruitment in acute respiratory distress syndrome. Minerva Anestesiol. 2011;77(4):418–426.
    1. Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, et al. Tidal volume lower than 6ml/kg enhances lung protection role of extracorporeal carbon dioxide removal. Anesthesiology. 2009;111(4):826–835.
    1. Bein T, Weber-Carstens S, Goldmann A, Müller T, Staudinger T, Brederlau J, et al. Lower tidal volume strategy (approximately ≈3 ml/kg) combined with extracorporeal CO2 removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med. 2013;39(5):847–856.
    1. Retamal J, Libuy J, Jiménez M, Delgado M, Besa C, Bugedo G. Preliminary study of ventilation with 4 ml/kg tidal volume in acute respiratory distress syndrome feasibility and effects on cyclic recruitment - derecruitment and hyperinflation. Crit Care. 2013;17(1):R16–R16.
    1. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guérin C, Prat G, Morange S, Roch A, ACURASYS Study Investigators Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–1116.
    1. Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L, PROSEVA Study Group Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–2168.
    1. Cornejo RA, Díaz JC, Tobar EA, Bruhn AR, Ramos CA, González RA. Effects of prone positioning on lung protection in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2013;188(4):440–448.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe